Studies conclude: Atrovent can't hurt

There does appear to be evidence that supports the theory that giving ipatropium bromide (Atrovent) for the treatment of asthma and COPD flare-ups in the emergency setting may be beneficial.

According to Aaron SD et al in 2001, the following results were discovered:

• Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted-average method. Use of nebulized ipratropium/beta2-agonist combination therapy was associated with a pooled 7.3% improvement in forced expiratory volume in 1 sec and a 22.1% improvement in peak expiratory flow compared with patients who received beta2-agonist without ipratropium. 
• Similarly, randomized controlled studies of pediatric asthma exacerbation and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta2-agonists improves lung function and also decreases hospitalization rates, especially among children with severe exacerbations of asthma. 
• The adult and pediatric studies did not report any severe adverse effects attributable to ipratropium when it was used in conjunction with beta2-agonists.
• In conclusion, there is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive to beta2-agonists for the treatment of acute asthma exacerbation. In pediatric asthma exacerbation, use of ipratropium also appears to improve clinical outcomes; however, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta2-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects. (1)

In a comparison of Ventolin given without Atrovent and Ventolin given with Atrovent, Watanasomsiri A1, Phipatanakul W. concluded:

Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group. (2)

They concluded:

Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies. (2)

In comparing treatments with ipatropium bromide alone, or albuterol alone, or both together, Ward et al concluded:

The two drugs in sequence produced greater bronchodilatation than either used alone, and the mean peak expiratory flow rate rose by 96% in four hours. Thus giving ipratropium bromide in addition to salbutamol in severe asthma enhances the bronchodilator effect. (3)

The bottom line here is that, while there is no conclusive evidence atrovent will help with acute exacerbations of asthma, side effects are negligible.  That seems to be the mantra for using most respiratory medications: it can't hurt.

Both medicines have received an expanded role, for not only are they prescribed together (usually in the form of Duoneb) for asthma patients, they are prescribed together for nearly all lung ailments, including those not proven to benefit from this type of therapy.

There are some physicians who will allow the respiratory therapist to limit the frequency of atrovent to every four hours.  However, there are many physicians who order Duoneb even for continuous breathing treatments.

So what are your thoughts?

References:

1. Aaron, SD, "The use of ipratropium bromide for the management of acute asthma exacerbation in adults and children: a systematic review," Journal of Asthma, October, 2001, 38 (7), pages 521-530, accessed on 5/18/14 http://www.ncbi.nlm.nih.gov/pubmed/11714074
2. Watanasomsiri A1, Phipatanakul W., "Comparison of nebulized ipratropium bromide with salbutamol vs salbutamol alone in acute asthma exacerbation in children," Anal of Allergy, Asthma and Immunology, May, 2006, 96 (5), pages 701-706, accessed 5/18/14, http://www.ncbi.nlm.nih.gov/pubmed/16729783
3. Ward, M.J., P.H. Fentem, W.H. Smith, and D. Davies, "Ipatropium Bromide in Acute Asthma," British Medical Journal, Feb. 21, 1981, 282 (6264), pages 598-600, accessed 5/18/14, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1504444/